Medication Errors and Medicines Optimisation RECORDING HARM FROM RESTRAINT TO THE NATIONAL REPORTING AND LEARNING SYSTEM (NRLS) Vanessa Gordon, Head of Patient Safety Mental Health, Learning Disability and Offender Health, NHS England Carol Boreham, Patient Safety Reporting Lead, National Reporting and Learning System Contents • Current data about restraint in the NRLS • Prone restraint reporting pilot (2014) • Review of current restraint reporting requirements for NRLS • A new guidance document for reporting organisations 2 Current data about restraint in the NRLS • Not attached to a restraint code • Only mentioned in the free text of another incident • No degree of harm available • Little description or investigation details Therefore the generation of learning about incidents resulting from restraint is not possible 3 Prone restraint reporting pilot (2014) • The aim of this pilot was to record the incidence and associated stories of all prone restraint events over a six week period in 3 Trusts (2 MH, 1 Acute) • All fields, including the degree of harm and the investigation information on the prone restraint incident form should be relating to the restraint itself • 5 questions asked of the reporters for each incident provided extra learning 4 Results of the Prone Restraint Pilot • Prone restraint incidents were successfully reported to the NRLS and the learning has generated an Alert • In two Trusts PMVA leads managed the quality of the data reported • Feedback from the MH organisations was negative around the time taken to report, although the learning was useful. MH Trusts concerned about all Prone restraint being considered a PSI • Acute Trust has adopted the pilot process and now routinely collects the 5 question learning for restraint incidents 5 Review of current restraint reporting requirements for NRLS • Any incident where the local restraint policy is not followed • Any incident where restraint resulted in harm to the patient • The code used to map these incidents for NRLS is N1100 (restraint) 6 A new guidance document for reporting organisations When restraint is performed for any reason whilst a person is receiving NHS funded care and physical harm occurs, even low harm, this is and has always been reportable to the NRLS as a separate incident to the original incident that led to restraint. This applies to any type of physical restraint. If the restraint is part of a care plan, it is still reportable if it causes harm to the patient. 7 All fields, including the incident description, degree of harm and the investigation information should be relating to the restraint itself. The degree of harm should be the actual harm to the patient resulting from the restraint. The incident description should contain: • The type or types of restraint used • The duration of each type of restraint • The events leading up to the restraint being used • Details about the harm to the patient • Details about what physical observations were undertaken and recorded during the restraint 8 Local Risk Management System changes • Organisations without a restraint incident type in their listing should add it • This incident type should be mapped to N1100 (restraint) • The NRLS Team provides helpdesk staff for advice and guidance to Trusts 9 Fresh start for restraint reporting to NRLS • All organisations in all care settings to be asked to report harm from restraint from April 2015 • All organisations in all care settings to ensure that restraint incidents are reported to the N1100 code. This will position the learning in a defined location in the NRLS to allow access 10 Contact Further information about the NRLS can be found at: www.nrls.nhs.uk The NRLS Reporting site can be found at: https://report.nrls.nhs.uk/nrlsreporting For NRLS Helpdesk enquiries, complete a contact form on the NRLS Reporting site or email [email protected] 11
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